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Based on staff interview, clinical record, administrative document and video recording review, the hospital failed to comply with the provisions of CFR 489.24 when:

One of twenty-five patients (Patient 1) did not receive a complete Medical Screening Exam (MSE) before being escorted by staff out of the Emergency Department (ED).

These failures to provide an MSE within the capabilities of the hospital resulted in preventable events that may have contributed to Patient 1's death.

Based on staff interview, clinical record, administrative document and video recording review, the hospital failed to ensure that 1 of 25 patients (Patient 1) received an appropriate medical screening exam (MSE). On 3/8/2017 at 51 minutes after midnight, Registered Nurse (RN) 4 and security guard (SG) 1 wheeled Patient 1 out of the Emergency Department and off hospital grounds after being brought in by ambulance. RN 4 did not confer with a medical provider to confirm Patient 1 had completed his MSE.

This failure resulted in Patient 1 not receiving a completed MSE, denied Patient 1's right to be treated in the ED, not being stabilized for a very high blood alcohol (454 mg/dl-milligrams per deciliter - normal is below 80 mg/dl), being left unattended near hospital property, and prompted preventable events that may have contributed to Patient 1's death.

Findings:

Patient 1's clinical record indicated he was a 40 year old male and was brought to the hospital's Emergency Department (ED) at 10:02p.m., on 3/8/17. The ambulance Emergency Medical Service (EMS) report indicated Patient 1 had complained of heart palpitations and that he appeared moderately intoxicated. The EMS report indicated Patient 1 would not answer questions but kept repeating, "Just take me to the hospital". The EMS report indicated Patient 1's heart rate (HR) was 124 (normal is 60 to 100 beats per minute) and respiratory rate (how many times you breath in and out per minute, RR) was 28 (normal is 12 to 20).

On 3/14/17 at 1:30p.m., during an interview, RN 2 stated his first interaction with Patient 1 was when EMS brought him in through the ambulance bay. He stated he asked Patient 1 how he was feeling and Patient 1 told him his head hurt. RN 2 stated he did not appear intoxicated. When Patient 1 was done with triage, RN 2 stated EMS took him to the lobby waiting room after which the Nurse Practitioner (NP) would see him.

Patient 1's "ED Triage Form" time stamped 10:12p.m., on 3/8/17 indicated his HR was 112 and his RR was 20 and he "c/o [complaint of] head injury, told EMS he was having palpitations." The "ED Triage Form" indicated Patient 1 was classified by RN 2 as an Emergency Severity Index (ESI- used to determine urgency of patient medical condition) of 3 (urgent but stable). Following the initial assessment by RN 2 the care of Patient 1 was handed off to RN 4. The clinical record indicated Patient 1 was sent to the triage area located within the lobby at 10:22p.m.

On 3/15/17 at 7:50a.m., during an interview, SG 1 stated he saw Patient 1 when he first came on shift at 11:00p.m., on 3/8/17. SG 1 stated Patient 1 was swearing at the nurses in the lobby triage station. SG 1 stated after being seen by the nurses Patient 1 went to the lobby waiting area and started carrying on a loud conversation with another patient. SG 1 stated the conversation was not hostile. SG 1 stated sometime later (he wasn't sure of the time) he saw RN 4 talking to Patient 1. Patient 1 was still swearing. SG 1 stated he approached RN 4 and told him, "We need to do something about him (Patient 1)". SG 1 said RN 4 told him he was going to get the practice Coordinator (RN PC 1-supervising RN). SG 1 stated RN PC 1 told him (SG 1) that they needed to escort him off property because he (Patient 1) was not cooperating. SG 1 then went and got a wheelchair. SG 1 stated he told Patient 1 "Sir, it's time to go, you have to go." Patient 1 got on the wheelchair and "we proceeded to escort him off property." On the way to the bus stop SG 1 stated RN PC 1 explained to Patient 1 that he couldn't be cursing in front of children and not cooperating.

On 3/15/17 at 8:25 a.m., during an interview, RN 4 stated Patient 1 was not assessed by the Nurse Practitioner (NP - determined to be a qualified medical professional) 1 when he was first brought into the ED. RN 4 stated EMS gave him a report of why Patient 1 was brought to the ED. RN 4 stated a short time later (RN 4 could not recall exact time) Patient 1 was called but he did not show up. RN 4 stated Patient 1 eventually showed up and was seen by the NP . RN 4 stated "at one point he (Patient 1) was wandering back and forth and I knew he was going to be a problem." RN 4 stated SG 1 came to him and told him Patient 1 was in the lobby waiting area cursing and acting inappropriately. RN 4 stated he had not noticed Patient 1's behavior at this time because they (the hospital ED) have a lot of inebriated, homeless people and he is used to these behaviors. RN 4 stated he then noticed there were children and women around and knew he had to do something. RN 4 approached Patient 1 and asked him to stop cursing. RN 4 stated Patient 1 said that he wanted to go home. RN 4 stated he wanted Patient 1 to go to the back (of the ED) but he (Patient 1) was uncooperative. RN 4 stated he wanted him (Patient 1) away from the kids so he went to talk to RN PC 1. RN 4 wanted the RN PC 1 to move him to the Green Zone (an area in the ED typically for patients with non-urgent problems). RN PC 1 talked to Patient 1 and offered him a bed but he refused. According to RN 4, RN PC 1 asked Patient 1 if he wanted to be seen by a medical provider and he refused stating he wanted to go home. They (RN PC 1 and SG 1) got Patient 1 a wheel chair and they wheeled Patient 1 out of the ED. RN 4 was asked if an AMA (Against Medical Advice) form was completed and he stated it never crossed his mind to get Patient 1 to sign an AMA form. RN 4 also stated it was a busy ED and sometimes paperwork or charting is not their priority. RN 4 stated he felt Patient 1 was capable of making sound decisions. RN 4 also stated he knew Patient 1 was intoxicated but not enough to hold against his will. RN 4 was asked if the buses ran at midnight and he stated "no". RN 4 stated it wasn't his call to take Patient 1 to the bus stop but he wasn't worried about him because the homeless are "resilient, resourceful."

On 3/15/17 at 9:25a.m., during an interview, the RN PC 1 stated he was working in the green zone when RN 4 approached him about Patient 1. RN 4 told him Patient 1 was cursing out loud. RN PC 1 stated he then went out and talked to SG 1 who told him the same thing. RN PC 1 told SG 1 if Patient 1 continued they may have to escort him off property. RN PC 1 stated that was their (hospital) practice if they are disruptive and don't stop. RN PC 1 approached Patient 1 and asked him to stop his behaviors. RN PC 1 stated he asked Patient 1 If he wanted to be seen (by a medical provider) but Patient 1 didn't want to be seen, he wanted to go home. RN PC 1 stated Patient 1's behavior was escalating and he kept saying he wanted to go home, so he (RN PC 1) made the decision to get a wheelchair and escort Patient 1 out of the ED and to the bus stop.

On 3/15/17 at 10:07a.m., during an interview, Medical Doctor (MD) 1 stated he did not see Patient 1 prior to him coming in as a code (a medical emergency requiring resuscitation and a coordinated response on the part of medical personnel). MD 1 stated in his practice he would have to evaluate the patient before making a decision whether to discharge. MD 1 stated a medical provider is the one qualified to determine if a patient is safe for discharge.

On 3/15/17 at 11:05a.m., during an interview, the NP 1 stated he called Patient 1 back to the "Quick Look" Triage area. (The Quick Look Triage area is the staffed by an RN and a medical provider and located within the lobby area and the purpose is to quickly assess patients in order to determine the next steps in care.) He stated Patient 1 was a little "wobbly" but otherwise stable. NP 1 asked Patient 1 what brought him to the ED. Patient 1 told him he had high blood pressure. NP 1 stated he asked Patient 1 a series of questions related to high blood pressure including if he had any dizziness or visual changes. Then Patient 1 told him he had a brain bleed and that he had an aneurysm (a weakening of blood vessel wall causing bulging). NP 1 stated he looked up the previous hospital records and confirmed Patient 1 did have a brain bleed in December 2016. NP 1 stated he asked Patient 1 if he had a headache. Patient 1 denied having a headache. NP 1 stated he then put in orders, based on his initial assessment. NP 1 explained the process of the "Quick Look Triage" is the initial assessment of the patient upon entry to the ED. "We do our best to determine what the patient needs. We do a quick look at the history, a quick exam, and put in orders." NP 1 stated that after the initial triage the patient goes to the treatment area. Normally the patient then waits in the internal waiting area (a waiting area within the treatment area of the ED, separated from the public lobby) for results (based on the orders the patient may have had, such as labs, x-rays or other procedures). NP 1 stated the following: The same medical provider or another medical provider follows up on the results and the patient is provided treatment, admitted, transferred, discharged or further diagnosis occurs. NP 1 stated no one notified him that Patient 1 was being wheeled out. In response to a question about a social service referral, NP 1 stated a social service referral is often put in during the initial assessment or whenever requested. NP 1 stated it could be put in at any point in the process if, "I considered it useful." NP 1 stated he did not order a social service referral for Patient 1. NP 1 stated he could not say based on his exam that an emergency medical condition did not exist.

The clinical record dated 2/16/17 for Patient 1 indicated a history of left brain bleed (left parietal parenchymal hemorrhage) which had occurred on 12/29/16. The clinical record also indicated Patient 1 had brain cell softening due to the bleed (also called medial left parietal subcortical cystic encephalomalacia). The clinical record indicated the following other problems: anemia (low red blood cells), coagulopathy (bleeding disorder), thrombocytopenia (low platelets) and acute hepatic encephalopathy which is a brain disorder related to chronic liver disease and chronic alcohol abuse.

On 3/15/17 at 2:05p.m., during an interview, the ED Director (ED Dir - the RN clinical leader of the ED) stated she was notified of the incident with Patient 1 early on the morning of 3/9/17. The ED Dir stated the normal process for a medical screening exam is the nurse does the assessment then a provider will see the patient following a process depending on what the patient presented with. ED Dir stated the MSE should consist of a focused assessment of the Patient's chief complaint, the ordering of labs or other appropriate tests and then determine the disposition of the patient: admit, transfer, or discharge the patient. ED Dir stated since Patient 1 did not stay the entire visit, the components of the MSE were not met. ED Dir stated if a patient wanted to leave before the MSE was complete, "Leaving against Medical Advice" (AMA) process and documents should have been completed by staff and signed by the patient; and the House Supervisor should have been notified Patient 1 wanted to leave AMA. ED Dir stated the AMA process was never initiated for Patient 1 and RN PC 1 did notify the House Supervisor prior to Patient 1 being wheeled out of the ED.

On 3/15/17 at 3:33p.m., during an interview, the Medical Director of the ED (Med Dir Ed) stated in the case of a patient that wants to leave AMA, it is common practice to notify a medical provider. Med Dir Ed stated, "Ideally every patient should have a conversation with their provider (regarding an AMA)." Med Dir Ed stated what happened with Patient 1 was not an acceptable practice but he didn't know how busy the ED was at that time. Med Dir Ed stated even though Patient 1 was not attempting to walk out of the ED he was "draining staff", "disruptive", and "manipulative."

On 3/16/17 at 7:48a.m., during an interview, RN PC 1 stated he did not inform a medical provider of the decision to escort Patient 1 off hospital property. RN PC 1 stated he did not remember other patients complaining about Patient 1 swearing. RN PC 1 stated he was familiar with Patient 1 from previous visits to the ED and felt that he had built a rapport with him. RN PC 1 stated he was concerned about the potential Patient 1 would become violent. RN PC 1 stated he had never witnessed Patient 1 becoming violent during his previous visits, but stated he always considers this to be a potential with any patient. RN PC 1 stated that on the way to the bus stop he discussed his (Patient 1's) cursing and behavior with him. He said Patient 1 apologized. RN PC 1 stated he considered taking him back to the ED after the apology but Patient 1 started cursing again so he didn't. RN PC 1 stated he was confident in the decision to escort Patient 1 out of the hospital and stated he would not do anything differently if given the opportunity to handle the situation again.

On 3/16/17 at 9:25a.m., during an interview, MD 2 stated he worked on the night of 3/8/17 to 3/9/17. He did not see Patient 1 and did not hear Patient 1 allegedly causing a disturbance. MD 2 stated, "No one came to see me regarding the patient (Patient 1). MD 2 stated if someone wanted to leave AMA a provider should talk to them about the risks and benefits.

Patient 1's clinical record dated 3/8/17, indicated the following labs were ordered; Blood alcohol level, (a blood test to measure the amount of alcohol in the blood) at 11:18p.m., Comprehensive Metabolic Panel, (a blood test to provide the level of electrolytes) at 11:18p.m., and a urine sample for drugs (a urine test to determine if controlled or illegal substances have been used by the patient) at 11:39p.m. Patient 1's alcohol level was 454.0 mg/dL (a unit of measure, .08 is equal to 80 mg/dL and is the legal limit for intoxication). Patient 1's urine was positive for Opiates and Tetrahydrocannabinol (or THC, the active ingredient in marijuana).

On 3/17/17 at 10:08a.m., during an interview, the Director of Quality, Risk and Accreditation (DQRA) stated she was aware of the incident involving Patient 1. The DQRA stated the incident indicated collaboration between RNs and medical providers was missing. The DQRA stated RN ED staff were undergoing mandatory EMTALA training.

On 3/17/17 at 10:36a.m., during an interview, the Chief Medical Officer (CMO) stated he was aware of the incident involving Patient 1. The CMO stated it is never acceptable when loss of life occurs. The CMO stated events surrounding this incident offer the hospital an opportunity to look at policy. The CMO stated the hospital will look very hard at everything around this case; it is happening now. The CMO stated RN PC 1 is training on and reinforcing AMA policy. CMO stated the hospital is looking at the triage process to make sure the hospital is doing what it is supposed to be doing. The CMO stated that he is aware the Quick Look triage is not a complete MSE. The CMO stated the hospital is re-teaching the RN ED staff about an appropriate MSE.

The hospital's security video of the lobby and exterior of the building was viewed. The video runs from 10:03p.m. On 3/8/17 when Patient 1 was brought into the hospital by EMS and then starts again at 11:36 p.m. on 3/8/17 through 1:10a.m. on 3/9/17. There was no audio. Patient 1 was identified as the patient with a cap on and a jean jacket and pants. At the 12:41:13 reading on the video file identified as 0028 to 0050 Patient 1 had his head down on the arm of the chair. This was the waiting area of the main ED lobby. SG 1 was seen approaching Patient 1. At 12:41:18 SG 1 stopped talking to Patient 1 and left. At 12:43:58 RN 4 was seen approaching Patient 1. Patient 1 had his head down on the arm of the chair and appeared to be sleeping. At 12:44:03 RN 4 tapped and then grabbed hold of Patient 1 on the shoulder and shook his shoulder back and forth a couple of times. Patient 1 stood up with an unsteady stance, was very wobbly and appeared to attempt to follow RN 4. Patient 1 then bent over at the waist, straightened up slightly and turned around and sat back down. RN4 walked back and spoke to Patient 1. Patient 1 didn't lift his head but had it face down. He leaned over and appeared to put his head on the arm of the chair. At 12:45:22, RN 4 left Patient 1. At 12:48:40 RN PC 1 was seen approaching Patient 1. RN 4 was a short distance from Patient 1 and RN PC 1. At 12:48:51 RN PC 1 was seen walking away from Patient 1 headed in the direction of the security desk. Patient 1 was still sitting in the chair. At 12:49:14 SG 1 and RN PC 1 approached Patient 1 with a wheelchair. At 12:49:52 Patient 1 was seen standing. He stood briefly at the chair, wobbly. He got into the wheelchair and SG 1 and RN PC 1 wheeled him out. On video labeled 0057 - 0112 ED Drive SG 1 was seen returning to the hospital with the empty wheelchair at 12:57:06. At 12:57:31 Patient 1 was seen entering the image on the left corner walking into the intersection. At 12:57:38 Patient 1 was seen putting his belongings on the street in front of a vehicle and then laying down. At 12:57:59 the vehicle was seen running over Patient 1.

The ED clinical record for Patient 1 dated 3/8/17 indicated under "History of Present Illness ...Patient [1] was found face down on the ground at the bus stop at the front of the hospital. CPR was started and the patient was brought to the ED. Patient had two rounds of CPR with no palpable pulse noted or cardiac activity noted on the US [ultrasound]. Another round of CPR was done on the patient. Upon pulse check there was cardiac activity noted on the US but there was no palpable pulse so CPR was re-started. After the fourth round of CPR there was no palpable pulses or cardiac activity noted on the US. Patient was then pronounced expired [1:23am on 3/9/17]".

The hospital policy and procedure titled, "Against Medical Advice (AMA): Left without Being Seen (LWBS)", dated April 2015, indicated: " ...Procedure: 1. Assess the patient's ability to understand their condition and the risks of leaving the hospital (vital signs, mental status, language, etc.). If competency is questionable, call/refer to Social Services. 2. Notify the attending physician, the manager/designee and /or Administrative Director of Nursing immediately of patient's intent to leave the hospital. 3. Inform the patient their physician is aware of their desire to leave. 4. Explain the patient's diagnosis/condition to the patient. 5. Explain the risks and consequences of leaving the hospital to the patient and family ...7. Involve available resources (i.e. social worker, chaplain, etc.) in an attempt to have the patient stay. 8. Complete 'Leaving Hospital Against Medical Advice' form ...when the patient (or responsible person) persists in wanting to leave the hospital prior to completion of treatment by the attending physician ...Procedure For Emergency Department: AMA: the same process as outlined above is followed, however the following forms are to be used: A. If the medical screening exam has not been provided, utilize 'Leaving Hospital Against Medical Advice Before Medical Screening Examination'. B. If the medical screening exam has been provided, utilize 'Leaving hospital Against Medical Advice After Medical Screening Examination'."

The hospital policy and procedure titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) transfer protocol", dated January 2015, indicated, " ...5. Medical Screening Examination (MSE): An examination, within the capability of the hospital, to determine whether the individual has an emergency medical condition. The triage assessment does not constitute a MSE ... B. Patient refusal to accept treatment or transfer against medical advice. 1) If an individual refuses treatment against medical advice, the risks and benefits of treatment must be explained. The patient is asked to sign the patient Refusal to Accept Examination and/or Treatment Against Medical Advice form ..."

The hospital policy and procedure titled "Emergency Services Policy and Procedure " dated 10/15 Index No. C-7 indicated under "Purpose: Charting guidelines for the emergency Department (ED). To Outline the responsibilities of the healthcare team member in documenting the status of a patient during their ED visit ...Definitions: 1. Quick Look Assessment: A brief visual assessment completed by the registered nurse (RN). Often only including a visualization of the presenting patient. This duty is to be performed by an experienced registered nurse who has received appropriate training in performing triage. .."

The hospital policy and procedure titled Emergency Services Policy and Procedure dated 10/15 Index No. A-4 with Subject: "Emergency Department Arrival Standards of Care" indicated under "Purpose: This policy serves to provide guidelines for the nursing care of Emergency Department [ED] patients prior to provider assessment. Outcome: ED patient care will be provided in a safe and consistent manner. Definitions: 1. Emergency Severity Index [ESI]: a five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups form 1 [most urgent] to 5 [least urgent] on the basis of acuity and resource needs ... 2. Medical Screening Exam [MSE]: an examination, within the capability of the hospital, to determine if the patient is experiencing an emergency medical condition. The triage assessment does not constitute a MSE. ..2. Quick Look Triage [QLT]: A rapid triage performed by the Triage Nurse in order to determine acuity and resource needs ..."